Communication Consent Form

Declaration

I consent to the practice contacting me by text message and/or email for the purposes of health
promotion, practice news and for appointment reminders.

I acknowledge that appointment reminders by text are an additional service and that
they may not be sent on all occasions but that the responsibility for attending
appointments or cancelling them still rests with me. I can cancel the text message
facility at any time.

Text messages are generated using a secure facility but I understand that they are
transmitted over a public network onto a personal telephone and as such may not
be secure, however the practice will not transmit any information which would enable
an individual patient to be identified.

Patient Name:

Date of Birth:

Home Tel:

Mobile No:

Email:

About This Form

Please Note

If more than one person shares the use of the mobile phone number detailed below,
we will need a consent form from each of those people.

By using this form, you will be sending information about yourself across the Internet.
Whilst every effort is made to keep this information secure, you should be aware
that we cannot offer any guarantees of absolute privacy. If this matter concerns
you then you should use another method to notify us of your details.

Personal Information

Personal information retained on this system is stored in a secure data centre located
in the UK and is treated as confidential.